A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Set client-centered, measurable and realistic goals.

Critically analyze client data to determine priorities.

Determine effectiveness of interventions.

Collect and organize client data.

Answer and Explanation

The Correct Answer is D

A. Set client-centered, measurable and realistic goals: This occurs during the planning stage, after data collection and analysis.

B. Critically analyze client data to determine priorities: This step happens after data collection during the diagnosis phase.

C. Determine effectiveness of interventions: This is part of the evaluation stage, which comes after planning and implementation.

D. Collect and organize client data: This is the first step in the nursing process, where the nurse gathers comprehensive information about the client's physical, psychological, sociocultural, developmental, and spiritual needs.

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Correct Answer is C

Explanation

A. Sheepskin heel pad: A sheepskin heel pad provides cushioning to prevent pressure ulcers but does not prevent plantar flexion contractures as it does not keep the foot in a neutral position.

B. Abduction pillow: An abduction pillow is used to maintain hip abduction and alignment, typically after hip surgery. It does not address foot positioning or prevent plantar flexion.

C. Footboard: A footboard helps maintain the feet in dorsiflexion, preventing plantar flexion contractures. It keeps the feet at a 90-degree angle to the legs, which is essential for preventing contractures.

D. Trochanter roll: A trochanter roll is used to maintain the alignment of the hips and prevent external rotation of the legs. It does not prevent plantar flexion contractures.

A. Testing visual acuity B. Observing for facial symmetry C. Eliciting the gag reflex D. Checking the pupillary response to light

Correct Answer is D

Explanation

A. Testing visual acuity: This assesses cranial nerve II (Optic nerve).

B. Observing for facial symmetry: This assesses cranial nerve VII (Facial nerve).

C. Eliciting the gag reflex: This assesses cranial nerves IX and X (Glossopharyngeal and Vagus nerves).

D. Checking the pupillary response to light: This assesses cranial nerve III (Oculomotor nerve), which controls pupil constriction and eye movements.

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A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Correct Answer is C

Explanation

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Correct Answer is D

Explanation

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